International Endodontic Journal (1998) 31, 155160

Review
New perspectives on radicular cysts: do they heal?
P. N . R . N A I R
Department of Oral Structural Biology, Centre of Dental and Oral Medicine, University of Zurich, Zurich, Switzerland

Summary presumed to serve as the source of epithelium that lines

the lumen in certain lesions that develop into radicular
During the past few decades several authors have
cysts.
perpetuated the notion that nearly half of all periapical
lesions are radicular cysts. A few studies, based on
meticulous serial sectioning of periapical lesions Incidence
retrieved in toto, have shown that the actual incidence
Radicular cysts are the most common of all jaw cysts
of radicular cyst is only about 15% of all periapical
and comprise about 52 (Shear 1992) to 68% (Killey et al.
lesions. Equally significant was the discovery in 1980
1977) of all the cysts affecting the human jaw. Their
and recent confirmation that radicular cysts exist in two
incidence is highest amongst patients in their third
structurally distinct classes namely, those containing
decade of life (Bhaskar 1966, Mortensen et al. 1970,
cavities completely enclosed in epithelial lining (peria-
Shear 1992) and are more common amongst men than
pical true cysts) and those containing epithelium-lined
amongst women (Bhaskar 1966, Shear 1992).
cavities that are open to the root canals (periapical
Anatomically the apical cysts occur in all tooth-bearing
pocket cysts). From a clinical point of view a periapical
sites of the jaw but are more frequent in maxillary than
pocket cyst may heal after conventional root canal
mandibular teeth. In the upper jaw the anterior region
therapy whereas an apical true cyst is less likely to be
appears to be more cyst-vulnerable whereas in the lower
resolved without surgical intervention.
jaw the radicular cysts occur more frequently in the
premolar region (Borg et al. 1974).
Keywords: apical periodontitis, apical pocket cysts,
radicular cysts, apical true cysts.
Prevalence amongst periapical lesions
Introduction A survey of literature shows that there have been several
studies on the prevalence of radicular cysts amongst
Radicular cysts are inflammatory jaw cysts at the apices
human periapical lesions (Table 1). The reported
of teeth with infected and necrotic pulps. The term cyst is
incidence of cysts amongst apical periodontitis lesions
derived from the Greek word Kystis meaning sac or
varies from 6 to 55%. Accurate histopathological
bladder. Chronic periapical lesions contain epithelial
diagnosis of radicular cysts is possible only through
cells (Malassez 1884, Thoma 1917, McConnell 1921,
serial sectioning or step-serial sectioning of the lesions
Freeman 1931, Sonnabend & Oh 1966, Seltzer et al.
removed in toto. There are only very few authors
1969, Summers 1974, Summers & Papadimitriou
(Sonnabend & Oh 1966, Simon 1980, Nair et al. 1996)
1975, Langeland et al. 1977, Yanagisawa 1980, Nair &
who used either one of those essential techniques. Most
Schroeder 1985, Nair & Schmid-Meier 1986), believed
of the investigators (Table 1) analyzed specimens
to be derived from the cell rests of Malassez (Malassez
obtained from wide sources for routine histopathological
1884), which proliferate in some lesions and are
reports. The 2308 lesions in Bhaskars study (Bhaskar
1966) were from 314 contributors and the 800 biopsies
of Lalonde & Luebke (1968) originated from 134
Correspondence: Dr P. N. R. Nair, Centre of Dental and Oral Medicine,
University of Zurich, Plattenstrasse II. CH-8028 Zurich, Switzerland. sources. Such histopathological diagnostic specimens,
This article is based on the authors work in the German language in often derived through apical curettage, do not represent
Endodontie 3, 169179 (1995). lesions in toto. In random sections from fragmented and

1998 Blackwell Science Ltd 155

156 P. N. R. Nair

Table 1 The incidence of radicular cysts amongst periapical lesions ture of a radicular cyst in relation to the root canal of the
Reference Cysts Granuloma Others Total affected teeth has not been taken into account. The
% % % lesions n major reason for this has been the nature of the biopsy
(Sommer 1966) 6 84 10 170 itself. Apical specimens removed by curettage do not
(Block et al. 1976) 6 94 230 contain the root-tips of the diseased teeth. Obviously,
(Sonnabend & Oh 1966) 7 93 237 structural reference to the root canals of the affected
(Winstock 1980) 8 83 9 9804*
teeth is not possible. Simon (1980) pointed out that
(Linenberg et al. 1964) 9 80 11 110
(Wais 1958) 14 84 2 50 there are two distinct categories of radicular cysts
(Patterson et al. 1964) 14 84 2 510 namely, those containing cavities completely enclosed in
(Nair et al. 1996) 15 50 35 256 epithelial lining, and those containing epithelium-lined
(Simon 1980) 17 54 23 35
cavities that are open to the root canals. Simon (1980)
(Stockdale &
Chandler 1988) 17 77 6 1108 designated the latter bay cysts. It seems that he
(Lin et al. 1991) 19 81 150 observed only the large type of such lesions with volumi-
(Nobuhara & nous cavities into which the root apices of the affected
Del Rio 1993) 22 59 19 150
teeth appeared to protrude. The photomicrographs in
(Baumann &
Rossman 1956) 26 74 121 the publication reveal severe damage of the
(Mortensen et al. 1970) 41 59 396 microanatomical relationship between the root apices
(Bhaskar 1966) 42 48 10 2308 and the cyst-epithelia. Furthermore, they do not repre-
(Spatafore et al. 1990) 42 52 6 1659
sent axial sections passing through the root canal. These
(Lalonde & Luebke 1968) 44 45 11 800
(Seltzer et al. 1967) 51 45 4 87 factors might have influenced critics to wonder whether
(Priebe et al. 1954) 55 46 101 the bay cysts (Simon 1980) are histological artefacts.
Table adapted from (Nair et al. 1996) * Number of operations
More recently, (Nair et al. 1996) analyzed 256 periapical
performed. The author does not explicitly say whether all the 9804 lesions obtained with extracted teeth. The specimens
biopsies were subjected to histopathological diagnosis. were processed by modern plastic-embedding technique
and meticulous serial or step-serial sections were
epithelialized lesions, part of the specimens can give the prepared and evaluated based on predefined histopatho-
appearance of epithelium-lined cavities that do not exist logical criteria. Out of the 256 specimens 35% were
in reality. Seltzer et al. (1967) defined a typical radicular found to be periapical abscess, 50% were periapical
cyst as one in which a real or imagined lumen was lined granulomas and only 15% were periapical cysts. Equally
with stratified squamous epithelium. It should be significant was the finding that two distinct classes of
pointed out that the photomicrographic illustrations in radicular cysts the apical true cysts, with cavities
many studies (Bhaskar 1966, Lalonde & Luebke 1968) completely enclosed in epithelial linings and the apical
represent only magnified views of selected small pocket cysts, with cyst-lumina open to the root canals
segments of epithelialized lesions. They are not sup- occur at the periapex when the lesions were analyzed in
ported by overview pictures of lesser magnifications of relation to the root canals. An overall 9% of the 256
sequential sections derived from different axial planes of lesions were apical true cysts and 6% were periapical
the lesions in question. The discrepancy in the reported pocket cysts.
incidence of periapical cysts is most probably due to the
difference in the histopathological interpretation of the Periapical true cyst
sections. When the histopathological diagnosis is based
on random or limited number of serial sections, most The periapical true cyst may be defined as a chronic
epithelialized periapical lesions would be wrongly inflammatory lesion at the periapex that contains an
classified as radicular cysts. This assumption is strongly epithelium lined, closed pathological cavity (Fig. 1). The
supported by the results of a most recent study (Nair pathogenesis of radicular cysts, presumably the true
et al. 1996) in which an overall 52% of the lesions (n = cysts, has been discussed by various authors (Thoma
256) were found to be epithelialized but only 15% were 1917, Rohrer 1927, Gardner 1962, Shear 1963, Main
actually periapical cysts. 1970, Ten Cate 1972, Torabinejad 1983). An apical
cyst is considered to be a direct sequel to apical granu-
loma, although a granuloma need not always develop
There are cysts and cysts
into a cyst. Due to still unexplainable reasons only a
In routine histopathological diagnostic work the struc- small fraction (< 10%) of the periapical lesions advance

1998 Blackwell Science Ltd, International Endodontic Journal, 31, 155160

 New perspectives on radicular cysts 157

formed by tissue necrosis and lysis because of the

inherent nature of the epithelial cells to cover exposed
connective tissue surfaces (McConnell 1921, Summers
1974). During the third phase the cyst grows the exact
mechanism of which is still unknown. It is generally
believed to be by osmosis. The presence of necrotic tissue
in the cyst lumen attracts neutrophilic granulocytes,
which extravasate and transmigrate through the epithe-
lial lining (Fig. 2) into the cyst cavity where they perish.
The lytic products of the dying cells in the cyst-lumen
release a greater number of molecules. As a result the
osmotic pressure of the cyst fluid rises to a level higher
than that of the tissue fluid (Toller 1970). The latter
diffuses into the cyst cavity so as to raise the intralu-
minal hydrostatic pressure well above the capillary
pressure. The increased intracyst pressure may lead to
bone resorption and expansion of the cyst. However, the
fact that an apical pocket cyst with lumen open to the
necrotic root canal can become larger (Nair et al. 1996,
Nair 1997) would eliminate osmotic pressure as a poten-
tial factor in the development of radicular cysts. On the

Fig. 1 (a) Periapical true cyst. Two sequential sections derived from
different axial planes (b, c) from the same lesion. Note the lumen (LU)
is completely enclosed in epithelium (EP). The rectangular demarcated
area in (b) is magnified in (a). D dentine; IC infiltrate cells.
Magnifications: a x130; b, c 325.

into true radicular cysts (Sonnabend & Oh 1966, Simon

1980, Nair et al. 1996). The process of the true cyst
formation has been discussed in three stages (Shear
1992). During the first phase the dormant cell-rests of
Malassez begin to proliferate, probably under the
influence of growth factors, cell mediators and metabo-
lites that are released by various cells residing in the
periapical lesion. During the second phase an epithelium
lined cavity comes into existence. There are two main
theories regarding the formation of the cyst cavity: (i)
the nutritional deficiency theory is based on the
assumption that the central cells of the epithelial strands
get removed from their source of nutrition and undergo
necrosis and liquefactive degeneration (James 1926, Hill
1930, Tratman 1939, Ten Cate 1972). The accumu- Fig. 2 Transmigration of neutrophilic granulocytes (PMN) across the
lating products in turn attract neutrophilic granulocytes epithelial wall (EP) of the cyst lumen (LU). (a) Represents magnified
into the necrotic area. Such microcavities containing view of the rectangular area demarcated in Fig. 1(a). Inset in (a) is an
degenerating epithelial cells, infiltrating mobile cells and intramural scanning electron microscopic view of a cyst wall. Note the
flat epithelial cells (EP) and the globular nutrophilic granulocytes
tissue fluid coalesce to form the cyst cavity lined by (NG). The latter emerge through the interepithelial spaces into the cyst
stratified epithelium, (ii) the abscess theory postulates lumen. CT, connective tissue; BV, blood vessels. Magnifications: a, b
that the proliferating epithelium lines an abscess cavity 3330; inset x670.

1998 Blackwell Science Ltd, International Endodontic Journal, 31, 155160

158 P. N. R. Nair
other hand, there is increasing evidence in support of a
molecular mechanism for cyst expansion (Nair 1997).
The macrophages (Nair 1997) and T-lymphocytes
(Torabinejad & Kettering 1985) in the cyst wall may
provide a continuous source of bone resorptive metabo-
lites (Formigli et al. 1995) and cytokines. The presence of
effector molecules such as matrix metalloproteinase-1
and 2 have also been reported in the cyst walls
(Teronen et al. 1995).
Periapical pocket cyst
The periapical pocket cyst is a radicular cyst containing
an epithelium-lined pathological cavity which is open to
the root canal of the affected tooth (Fig. 3). As has been
mentioned previously such lesions were originally
described as bay cysts (Simon 1980) and has been
recently investigated in detail and renamed as the
periapical pocket cysts (Nair et al. 1996). It is postu-
lated that a pocket cyst is initiated by a small bubble-like
extension of the infected root canal space into the
periapex. The microluminal space is enclosed in a
Fig. 3 Periapical pocket cyst. Axial sections passing peripheral to the
root canal (a) give the false impression of the presence of a cyst lumen
(LU) completely enclosed in epithelium. Sequential section passing
through axial plane of the root canal (RC) clearly reveals the conti-
nuity of the cystic lumen with the root canal (RC). The rectangular
area in (b) is magnified in (c). Note the pouch-like lumen (LU) of the
pocket cyst with the epithelium (EP) forming a collar at the root apex.
Magnifications: a, b 321; c 350.
stratified squamous epithelium which grows and forms
an epithelial collar (Fig. 3c) around the root tip. The
epithelial collar forms an epithelial attachment (Nair &
Schroeder 1985) to the root surface so as to seal off the
infected root canal and the microcystic lumen from the
periapical milieu. The presence of micro-organisms in
the apical root canal attracts neutrophilic granulocytes
by chemotaxis into the microlumen. However, the
pouch-like lumen biologically outside the body milieu
acts as a death trap and garbage bag to the external-
ized and dying neutrophils. As the necrotic tissue and
microbial products accumulate, the sac-like lumen
enlarges to accommodate the debris to form a volumi-
nous diverticulum of the root canal space into the
periapical area (Fig. 3c). It has been pointed out (Nair
et al. 1996) that from the pathogenic, structural, tissue
dynamic and host-beneficial and protective stand points,
the epithelium-lined pouch-like extension of the root
canal space of such lesions has much in common with a
marginal periodontal pocket so as to justify the termi-
nology of periapical pocket cyst as against a biologically
meaningless nomenclature of bay cyst (Simon 1980).
Do radicular cysts heal?
The prevalence of two distinct classes of radicular cysts
and the low incidence of true cysts (< 10%) amongst
periapical lesions has much significance in oral surgery
and clinical endodontics. Oral surgeons generally hold
the view that cysts do not heal and have to be removed
by surgery. It should be pointed out with emphasis that
in spite a recent claim (Shrout et al. 1993) periapical
lesions cannot be differentially diagnosed into cystic and
noncystic lesions based on radiographic evidence alone
(Priebe et al. 1954, Baumann & Rossman 1956, Wais
1958, Linenberg et al. 1964, Bhaskar 1966, Lalonde
1970, Mortensen et al. 1970). However, routine
histopathological diagnostic laboratories and publica-
tions based on reviewing such reports perpetuate the
notion that nearly half of all periapical lesions are radic-
ular cysts. As a result a disproportionately large number
of surgical interventions are done at the tooth-apex to
enucleate lesions that are diagnosed clinically as cysts.
In fact studies based on meticulous serial sections have
shown that the incidence of true radicular cysts is less
than 10% of all periapical lesions (Sonnabend & Oh
1966, Simon 1980, Nair et al. 1996). This would imply
that most of the cases in which apical surgery has been
performed based on radiographic diagnosis of the
presence of cysts might have resolved by conventional
root canal therapy.
1998 Blackwell Science Ltd, International Endodontic Journal, 31, 155160

On the other hand, many clinicians are of the opinion
that a great majority of cysts heal after conventional
root-filling-therapy. A success rate of 8590% has been
recorded by many practitioners and endodontic investi-
gators (Staub 1963, Kerekes & Tronstad 1979,
Barbakow et al. 1981, Sjgren et al. 1990). However, the
histological status of any apical radiolucent lesion at the
time of treatment is unknown to the clinician and
he/she is unaware of the differential diagnostic status of
the successful and failed cases. However, most of the
cystic lesions must heal in order to account for the high
success rate after conventional root canal treatment
and the observed high incidence of radicular cysts. We
have already seen how several investigators listed in
Table 1 reached the erroneous conclusion of high cyst-
incidence based on incorrect diagnosis of epithelialized
periapical lesions.
The clinical impact of the structural difference
between the apical true cysts and the apical pocket cysts
Fig. 4 Longitudinal radiographs of a periapically affected central
maxillary incisor of a 37-year-old woman for a period of 4 years and
9 months. Note the large radiolucent asymptomatic lesion before (a),
44 months after root-filling (b), and immediately after periapical
surgery (c). The periapical area shows distinct bone healing 1 year
post-operatively. Histopathological examination of the surgical
specimen by modern tissue processing and step-serial sectioning
technique has confirmed that the lesion was a true radicular cyst.
(Selected radiographs from P.N.R. Nair et al. Int Endod J 1993,
26:225233).
1998 Blackwell Science Ltd, International Endodontic Journal, 31, 155160
New perspectives on radicular cysts 159
should also be considered. The aim of conventional root
canal therapy has been the elimination of infectious
agents from the root canal and the prevention of reinfec-
tion by obturation. A periapical pocket cyst is, likely
therefore, to heal after conventional root canal therapy
(Simon 1980). The tissue dynamic of a true cyst is self-
sustaining however, as the lesion is no longer dependent
on the presence or absence of irritants in the root canal.
Therefore, true cysts, particularly the large ones, are less
likely to be resolved by conventional root canal therapy
(Fig. 4). This has been clearly shown in a longitudinal
follow-up of a case (Nair et al. 1993).
The low incidence of periapical cysts and the existence
of two distinct classes of cystic lesions at the periapex call
for a rethinking of the rationale behind some of the
diagnostic and therapeutic procedures currently
practised in oral surgery and clinical endodontics such
as: (i) routine histopathological examination of peri-
apical lesions removed by curettage, (ii) performing
disproportionately large numbers of apical surgery
based on radiographic diagnosis of a periapical lesion as
a radicular cyst, (iii) the widely held notion amongst
endodontists that a large majority of cysts heal after
conventional root filling therapy and (iv) the decision to
re-treat an asymptomatic, post-therapeutically persist-
ing periapical lesion instead of adopting apical surgery
as the treatment of choice under those clinical circum-
stances.
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